CMS Clarifies that Medicare Covers Maintenance Care

William “Chip” Hazelrig gets ongoing therapy from Shepherd Center via a research program, but anyone on Medicare also is eligible for maintenance care.

After years of legal battles, the Centers for Medicare and Medicaid Services issued a clarification on August 28 that Medicare coverage for skilled nursing facilities, home health and outpatient therapies is to be determined based on a person’s need, rather than their potential for improvement.

The clarification is the final step in a corrective action plan prescribed by a federal judge earlier this year, as a result of CMS’ failure to properly implement a 2013 judicial settlement over their coverage policies. The lawsuit, Jimmo v Sebelius (2011), came about as the result of Medicare denying coverage for maintenance care — nursing, home health and outpatient therapy — for those with chronic disabilities because they were not showing improvement in their prognosis. The plaintiffs argued the federal guidelines mandated that Medicare was required to cover skilled care for those who needed it to maintain their current level, or to slow a decline in their health or function.

The judge agreed, and in 2013 a settlement was put into place that required CMS to eliminate the “improvement requirement” and to make this policy change explicit to providers, beneficiaries and contractors. For years afterward, many people were still being denied access to maintenance care and therapy.

According to the Center for Medicare Advocacy, which filed the lawsuit, “Lawyers for the Jimmo plaintiff class requested further action from the court when it became clear that too many people were still being wrongfully denied Medicare coverage — in part because many health care providers had not been adequately educated, and in part because many providers were still skeptical that Medicare would alter its coverage practices.”

Advocates hope that this court-mandated clarification will be enough to convince providers that they will be reimbursed for providing maintenance services for those living with chronic disabilities.

“People living with MS, Parkinson’s, Alzheimer’s, paralysis and other long-term conditions have waited long enough for this relief,” said Judith A. Stein, executive director for the Center for Medicare Advocacy, in a press release. “We hope that the new CMS education and information, which can be found at CMS.gov and printed out with the CMS logo, will help convince providers that Medicare really is available for people who need this critical maintenance care.”